RESUMEN
We investigated the influence of the extent of viability using low dose dobutamine wall motion score index (WMS) on the survival benefit of surgical revascularization (CABG) versus medical therapy. In the STICH trial, viability assessment was not helpful in determining the benefit of CABG. However, the extent of viable myocardium with contractile function was not assessed in the trial. Dobutamine echocardiography was performed in 250 patients with ischemic left ventricular dysfunction (125-medically treated, 125-CABG). The mean ejection fraction (EF) was 32% in both groups. WMS during low dose dobutamine infusion was used to classify patients into groups with extensive (WMS < 2.00), intermediate (WMS 2.00-2.49), and limited (WMS ≥ 2.50) viability. Survival free of cardiac death was assessed at 2 years and for the complete duration of follow-up. There were 44 (35.2%) and 67 (53.6%) cardiac deaths in the revascularized and medically treated patients respectively (follow-up of 5.7 ± 5.8 years). Revascularized and medically treated patients with extensive viability had similar 2-year survival (p = 0.567) but revascularized patients had improved long-term survival (p = 0.0001). In those with intermediate viability, revascularization improved both 2 year (p = 0.014) and long-term survival (p = 0.0001). In patients with limited viability, 2-year survival was worse in revascularized patients (p = 0.04) and long-term survival was similar (p = 0 .25) in revascularized and medically treated groups. Patients with extensive and intermediate amounts of viability have improved survival with CABG but those with limited viability have poorer short-term outcome and no long-term benefit.
Asunto(s)
Cardiomiopatías/diagnóstico por imagen , Cardiotónicos/administración & dosificación , Puente de Arteria Coronaria , Dobutamina/administración & dosificación , Ecocardiografía de Estrés/métodos , Isquemia Miocárdica/diagnóstico por imagen , Volumen Sistólico , Disfunción Ventricular Izquierda/diagnóstico por imagen , Función Ventricular Izquierda , Anciano , Cardiomiopatías/mortalidad , Cardiomiopatías/fisiopatología , Cardiomiopatías/cirugía , Fármacos Cardiovasculares/uso terapéutico , Toma de Decisiones Clínicas , Femenino , Humanos , Masculino , Persona de Mediana Edad , Isquemia Miocárdica/mortalidad , Isquemia Miocárdica/fisiopatología , Isquemia Miocárdica/cirugía , Miocardio/patología , Selección de Paciente , Valor Predictivo de las Pruebas , Recuperación de la Función , Estudios Retrospectivos , Factores de Riesgo , Factores de Tiempo , Supervivencia Tisular , Resultado del Tratamiento , Disfunción Ventricular Izquierda/mortalidad , Disfunción Ventricular Izquierda/fisiopatología , Disfunción Ventricular Izquierda/cirugíaRESUMEN
OBJECTIVES: We examined outcomes of patients resuscitated from cardiac arrest owing to ST-segment elevation myocardial infarction (STEMI) and predictors of survival and neurologic recovery. BACKGROUND: Immediately after resuscitation from cardiac arrest owing to STEMI, many patients show signs of neurologic impairment, and benefits of percutaneous coronary intervention and subsequent prognosis are not well defined. METHODS: Between January 1, 2002, and December 31, 2006, we retrospectively identified consecutive patients resuscitated from cardiac arrest, regardless of time to return of spontaneous circulation (ROSC) and neurologic status, and reviewed the outcomes of those who had STEMI. Mortality and neurologic recovery at discharge and long-term mortality were assessed by individual chart review for those who underwent emergent angiography. RESULTS: Our study population consisted of 98 patients; 64% survived to discharge, and 92% had a full neurologic recovery. Predictors of survival were shorter time to ROSC, younger age, neurologic status post-resuscitation (alert or minimally responsive), and male sex. Predictors of neurologic recovery included shorter time to ROSC, neurologic status post-resuscitation (alert or minimally responsive), and younger age. Ninety-six percent of patients who were alert post-resuscitation survived. Ninety-three percent of patients who were minimally responsive post-resuscitation survived. Fifty-nine patients were unresponsive post-resuscitation, with 44% survival, of whom 88% had full neurologic recovery. In the unresponsive group, unwitnessed arrest, prolonged ROSC, and older age were associated with increased risk of death, and older age and prolonged ROSC predicted poor neurologic recovery. CONCLUSIONS: When resuscitated patients with STEMI are being evaluated in the emergency department, serious consideration should be given to emergent angiography and revascularization, regardless of neurologic status.